The problems of childhood were initially seen simply as downward extensions of adult-oriented diagnoses. The prevailing view was one of children as “miniature adults.” But this view failed to recognize special problems, such as those associated with the developmental changes that normally take place in childhood or adolescence. Only relatively recently have clinicians come to realize that they cannot fully understand childhood disorders without taking these developmental processes into account. Today, even though great progress has been made in providing treatment for disturbed children, facilities are still inadequate to the task, and most children with mental health problems do not receive psychological attention.
The number of children affected by psychological problems is considerable. Research studies in several countries have provided estimates of childhood disorders. Roberts, Roberts, et al. ( 2007 ) found that 17.1 percent of adolescents in large metropolitan areas of the United States meet the criteria for one or more DSM diagnoses. Verhulst ( 1995 ) conducted an evaluation of the overall prevalence of childhood disorder based on 49 studies involving over 240,000 children across many countries and found the average rate to be 12.3 percent. In most studies, maladjustment is found more commonly among boys than among girls; however, for some diagnostic problems, such as eating disorders (see Chapter 8 ), rates are higher for girls than for boys. The most prevalent disorders are attention-deficit/hyperactivity disorder (ADHD) (Ryan-Krause et al., 2010 ) and separation anxiety disorders (Cartwright-Hatton et al., 2006 ). Some subgroups of the population—for example, Native Americans—tend to have higher rates of mental disorders. One study reported that 23 percent of the Native American children rated in the sample met criteria for 1 of the 11 mental disorders in the survey and 9 percent met criteria for 2 or more of the disorders (Whitbeck et al., 2006 ).
Maladaptive Behavior in Different Life Periods
Several behaviors that characterize maladjustment or emotional disturbance are relatively common in childhood. Because of the manner in which personality develops, the various steps in growth and development, and the differing stressors people face in childhood, adolescence, and adulthood, we would expect to find some differences in maladaptive behavior in these periods. The fields of developmental science (Hetherington, 1998 ) and, more specifically, developmental psychopathology (Kim-Cohen, 2007 ) are devoted to studying the origins and course of individual maladaptation in the context of normal growth processes.
It is important to view a child’s behavior in the context of normal childhood development (Silk et al., 2000 ). We cannot consider a child’s behavior abnormal without determining whether the behavior in question is appropriate for the child’s age. For example, temper tantrums and eating inedible objects might be viewed as abnormal behavior at age 10 but not at age 2. Despite the somewhat distinctive characteristics of childhood disturbances at different ages, there is no sharp line of demarcation between the maladaptive behavior patterns of childhood and those of adolescence, or between those of adolescence and those of adulthood. Thus, although our focus in this chapter will be on the behavior disorders of children and adolescents, we will find some inevitable carryover into later life periods.
Varying Clinical Pictures
The clinical picture of childhood disorders tends to be distinct from the clinical picture of disorders in other life periods. Some of the emotional disturbances of childhood may be relatively short lived and less specific than those occurring in adulthood. However, some childhood disorders severely affect future development. One study found that individuals who had been hospitalized as child psychiatric patients (between the ages of 5 and 17) died early in life due to unnatural causes (about twice the rate of the general population) when followed up from 4 to 15 years later (Kuperman et al., 1988 ). The suicide risk among some disturbed adolescents is long-lasting and requires careful follow-up and attention (Fortune et al., 2007 ). Suicidal thoughts are not uncommon in children. Riesch and colleagues ( 2008 ) report that 18 percent of sixth graders have thoughts of killing themselves. Two other recent studies have reported rates for children under age 15. Dervic, Brent, and Oquendo ( 2008 ) report that international suicide rates are 3.1 per million. Hawton and Harriss ( 2008 ) report that the long-term risk of suicide is 1.1 percent, with girls more likely than boys to commit suicide. Both studies report that difficult family relationships are the leading cause of suicidal behavior. Being bullied by another child is another factor that has been found to be associated with risk of suicide (Rivers & Noret, 2010 ).
Special Psychological Vulnerabilities of Young Children
Young children are especially vulnerable to psychological problems (Ingram & Price, 2001 ). In evaluating the presence or extent of mental health problems in children and adolescents, one needs to consider the following:
· • They do not have as complex and realistic a view of themselves and their world as they will have later; they have less self- understanding; and they have not yet developed a stable sense of identity or a clear understanding of what is expected of them and what resources they might have to deal with problems.
· • Immediately perceived threats are tempered less by considerations of the past or future and thus tend to be seen as disproportionately important. As a result, children often have more difficulty than adults in coping with stressful events (Mash & Barkley, 2006 ). For example, children are at risk for posttraumatic stress disorder after a disaster, especially if the family atmosphere is troubled—a circumstance that adds additional stress to the problems resulting from the natural disaster (Menaghan, 2010 ).
· • Children’s limited perspectives, as might be expected, lead them to use unrealistic concepts to explain events. For young children, suicide or violence against another person may be undertaken without any real understanding of the finality of death.
· • Children also are more dependent on other people than are adults. Although in some ways this dependency serves as a buffer against other dangers because the adults around him or her might “protect” a child against stressors in the environment, it also makes the child highly vulnerable to experiences of rejection, disappointment, and failure if these adults, because of their own problems, ignore the child (Lengua, 2006 ).
· • Children’s lack of experience in dealing with adversity can make manageable problems seem insurmountable (Scott et al., 2010 ). On the other hand, although their inexperience and lack of self-sufficiency make them easily upset by problems that seem minor to the average adult, children typically recover more rapidly from their hurts.
The Classification of Childhood and Adolescent Disorders
Until the 1950s no formal, specific system was available for classifying the emotional or behavioral problems of children and adolescents. Kraepelin’s ( 1883 ) classic textbook on the classification of mental disorders did not include childhood disorders. In 1952, the first formal psychiatric nomenclature (DSM-I) was published, and childhood disorders were included. This system was quite limited and included only two childhood emotional disorders: childhood schizophrenia and adjustment reaction of childhood. In 1966, the Group for the Advancement of Psychiatry provided a classification system for children that was detailed and comprehensive. Thus, in the 1968 revision of the DSM (DSM-II), several additional categories were added. However, growing concern remained—both among clinicians attempting to diagnose and treat childhood problems and among researchers attempting to broaden our understanding of childhood psycho-pathology—that the then-current ways of viewing psychological disorders in children and adolescents were inappropriate and inaccurate for several reasons. The greatest problem was that the same classification system that had been developed for adults was used for childhood problems even though many childhood disorders, such as autism, learning disabilities, and school phobias, have no counterpart in adult psychopathology. The early systems also ignored the fact that in childhood disorders, environmental factors play an important part in the expression of symptoms—that is, symptoms are highly influenced by a family’s acceptance or rejection of the behavior. In addition, symptoms were not considered with respect to a child’s developmental level. Some of the problem behaviors might be considered age appropriate, and troubling behaviors might simply be behaviors that the child will eventually outgrow. In the most recent revision of the diagnostic and statistical manual (DSM-5), efforts were made to provide diagnostic classification that is consistent with current research and contemporary clinical practice.